Blog | Monday, March 12, 2012

Going beyond tobacco, alcohol and drugs during the social history

As I am on service, I realized that one thing that can be easily lost in the race to take care of patients with limited duty hours: the social history. The social history is part of the admission "history and physical" that once included a myriad of information about the patient's job, life, and habits has now "fallen into despair" becoming little more than "negative for TED", or in other words "no tobacco, alcohol (ethanol) or drugs."

But, there is so much more to it than that. How do they afford to pay for their housing, food, and medications? Do they have insurance? Where do they live? Who takes care of them or do they take care of someone else? Do they have friends or family living nearby? What do they like to do for fun? Given that most of the discharge planning focuses on these elements of the social history, it seems silly that we don't include more than just "no TED."

So, when I was asked by a very astute medical student if I preferred to hear more in the social history, I said yes. The information that is usually discussed as the patient gets better and we wonder where they will go was now presented on admission, discussed as a problem just like any other medical problem.

In just a few short days, we discerned that a patient who had chronic hypoxia and shortness of breath worked in a factory which likely contributes to his interstitial lung disease. Another patient who had been hospitalized for alcohol withdrawal recently broke up with a girlfriend, which triggered this bout of drinking. Another patient who was a Jehovah's Witness would rather have IV therapy for his wound infection than surgery. Another patient with repeated hypertensive crisis had skipped his medications since he could not afford them.

Given the tremendous burden of costs of medications and the complex interplay between social factors and health, it's time that we start teaching people to take a thorough social history. Wondering what should go into a thorough social history, I first did what most physicians do: I went online. It turns out that Wikipedia has an entry on social history for medicine that starts out with the same substance abuse history. It also includes occupation, sexual preference, prison, and travel.

I stumbled upon another interesting piece by a medical student in the Los Angeles Times who admits that it is easy to skimp on the social history due to the time it takes to take a complete history. After a brief foray in PubMed, a study demonstrated that internal medicine residents do not often know the social history of patients, and this worsens if the resident is more advanced in training and when the workload is higher. Then, I recalled the seminal text that is still in use today. According to the Bates Guide to History and Physical Examination:

"The Personal and Social History captures the patient's personality and interests, sources of support, coping style, strengths, and fears. It should include occupation and the last year of schooling; home situation and significant others; sources of stress, both recent and long-term; important life experiences, such as military service, job history, financial situation, and retirement; leisure activities; religious affiliation and spiritual beliefs; and activities of daily living (ADLs).

"It also conveys lifestyle habits that promote health or create risk such as exercise and diet, including frequency of exercise; usual daily food intake; dietary supplements or restrictions; and safety measures and other devices related to specific hazards. You may want to include any alternative health care practices. You will come to thread personal and social questions throughout the interview to make the patient feel more at ease."

There is another good reason to teach the social history. Another study shows that those residents who took better social histories were actually perceived to be more humanistic. As others stated, "By knowing patients better--and taking better social histories--we will provide better care and will be more fulfilled and energized in our work as physicians."

Vineet Arora, MD, is a Fellow of the American College of Physicians. She is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist, supervising internal medicine residents and students caring for general medicine patients, and serves as a career advisor and mentor for several medical students and residents, and directs the NIH-sponsored Training Early Achievers for Careers in Health (TEACH) Research program, which prepares and inspires talented diverse Chicago high school students to enter medical research careers. This post originally appeared on her blog, FutureDocs.